To the Editor:
The term paraffinoma refers to a chronic granulomatous response to injection of paraffin, silicone, or other mineral oils into skin and soft tissue. Paraffinomas develop when the material is injected into the skin for cosmetic purposes to augment or enhance one’s appearance. Although they may occur in any location, the most common sites include the breasts and buttocks. The penis is a rare but emerging site for paraffinomas.1-3 We present a rare case of recurrence of a penile paraffinoma following surgical resection.
A 26-year-old uncircumcised Trinidadian man presented with a 5-cm, exquisitely tender tumor involving the penile shaft and median raphe that rapidly evolved over the course of 3 weeks (Figure 1). He presented with inability to urinate, attain an erection, or ambulate without notable tenderness. Additionally, he developed swelling of the penis and surrounding tissue. He had no other medical comorbidities; however, 1 year prior he presented to a urologist with a 1-cm nodule involving the median raphe that was surgically resected and required circumcision. Biopsy at the time of his surgical procedure revealed an exuberant foreign body giant cell reaction with surrounding empty spaces in the dermis resembling Swiss cheese, consistent with a paraffinoma (Figure 2). The recurrent tumor, which was 5 times the size of the initial nodule, was biopsied. Again, histopathologic findings were consistent with a paraffinoma with extensive dermal fibrosis and absence of polarizable material.
Figure 1. Hyperpigmented firm, mobile, 5-cm tumor involving the penile shaft, frenulum, and scrotum caused by paraffin injections.
Figure 2. A, Histopathology revealed a square-shaped biopsy with extensive dermal fibrosis and scattered empty spaces in the dermis resembling Swiss cheese consistent with paraffinoma (H&E, original magnification ×10). B, High-power magnification revealed a foreign body giant cell reaction with surrounding empty cystlike spaces in the dermis and dermal fibrosis (H&E, original magnification ×40).
The patient underwent extensive reconstructive surgery requiring skin grafting to the penile shaft. Given the size and location of this recurrent tumor with the ability to destroy vital urologic and reproductive function, consideration for prevention of recurrent episodes included novel therapeutic treatment options to suppress inflammation and fibrosis with doxycycline and nicotinamide.
Paraffin injections are used for cosmetic enhancement and most often occur in a nonclinical setting without medical supervision, as they are not US Food and Drug Administration–approved medical injectable materials. Examples of oils injected include paraffin, camphorated oil, cottonseed or sesame oil, mineral oil, petroleum jelly, and beeswax. These oils are not hydrolyzed by tissue lipases but are instead treated as a foreign body substance with subsequent granuloma formation (also known as sclerosing lipogranuloma), which can occur many years after injection.4 The granulomatous response may be observed months to years after injection. The paraffinoma normally affects the injection site; however, regional lymphadenopathy and systemic disease has been reported.2 Histopathologic findings are characteristic and consist of a foreign body giant cell reaction, variably sized round to oval cavities within the dermis, and varying degrees of dermal fibrosis.5
In 1899, mineral oil was first injected into male genitalia to restore architecture in a patient’s testicles following bilateral orchiectomy. After the success of this endeavor, mineral oil injections were used as filler for other defects.3 However, by 1906 the complications of these injections became public knowledge when 2 patients developed subcutaneous nodules after receiving injections for facial wrinkles.2 Despite public knowledge of these complications, penile paraffin injections continued to occur both in medical and eventually nonmedical settings.